Bradycardia Associated with Steroid Use for Laryngeal Edema in an Adult: A Case Report and Literature Review.

Steroids are used for specific indications in the perioperative period to reduce laryngeal or spinal cord edema, or for prophylaxis and treatment of postoperative nausea and vomiting. Given the other potential causes for hemodynamic alterations in the perioperative setting, it is important for physicians to be aware of cardiovascular side effects of short term steroids. Changes in blood pressure and heart rate, cardiac dysrhythmias, and even death have been described in patients receiving short term intravenous steroids. Bradycardia has been reported following short term methylprednisolone and dexamethasone therapy in both adult and pediatric patients. There are only two case reports in the literature of bradycardia following short term intravenous dexamethasone use in adult patients. This is the first case report that describes bradycardia following the use of dexamethasone in the postoperative setting for management of laryngeal edema in an adult. Telemetry and twelve lead electrocardiograms revealed sinus bradycardia and correlated directly with administration of dexamethasone in our patient. Bradycardia resolved following discontinuation of dexamethasone. We advocate for hemodynamic monitoring in patients receiving more than one dose of intravenous steroid therapy in the perioperative period, especially those with known cardiac and hepatic comorbidities and those taking medications with negative chronotropic effects.

Evaluating the potential benefits of metformin in patients with cardiovascular disease and heart failure.

OBJECTIVE: To examine the safety and potential benefits of metformin in diabetic patients with cardiovascular (CV) disease and heart failure (HF). DATA SOURCES: Searches of MEDLINE and International Pharmaceutical Abstracts (1966-August 2012). Search terms included metformin, lactic acidosis, cardiovascular disease, diabetes, heart failure, and clinical trials. STUDY SELECTION AND DATA EXTRACTION: Published studies and case reports that were chosen for inclusion evaluated the benefit and safety of metformin in patients with diabetes with CV disease and HF. DATA SYNTHESIS: Case reports and retrospective trials have failed to illustrate an association with metformin use and lactic acidosis in patients with HF or cardiac disease. In fact, the evidence has suggested that these patients may actually benefit from the use of metformin. CONCLUSIONS: Results from recent trials have evaluated the potential clinical advantages of metformin in patients with cardiac disease and HF. These studies have illustrated a favorable morbidity and mortality profile for the use of metformin in these patient populations. While large prospective trials are still needed to display conclusive evidence, the recent clinical trials suggest a benefit in areas where metformin use has previously been discouraged.

Evaluation of a pharmacy-driven inpatient discharge counseling service: impact on 30-day readmission rates.

OBJECTIVE: To evaluate the impact of a pharmacy-driven inpatient discharge counseling service on 30-day readmission rates. DESIGN: A retrospective electronic chart review was performed comparing internal medicine patients who received pharmacy discharge counseling with those who received the standard discharge process between May 1, 2011, and March 28, 2012. SETTING: A community teaching hospital's internal medicine service. PATIENTS: A total of 1,536 patients discharged from the internal medicine service were eligible for study inclusion. A total of 228 of these patients received pharmacy discharge counseling. INTERVENTIONS: Patients were screened for readmission risk. For those patients who scored as high risk, an attempt was made to provide pharmacy counseling and a discharge medication list. MAIN OUTCOMES MEASURES: The primary endpoint was to evaluate whether pharmacy discharge counseling had an impact on readmission rates. An additional outcome was to measure the quantity of pharmacy interventions. RESULTS: Out of the 228 patients who received pharmacy discharge counseling, 18.9% were readmitted within 30 days of hospital discharge, which was similar to the readmission rate for high- and moderate-risk patients who did not receive counseling (18.8% and 18.9%, respectively). But, after stratification based on readmission risk, the moderate-risk, pharmacy-counseled group had a significantly lower readmission rate than the moderate-risk control group (3.8% vs. 18.9%; P=0.033). Overall, 915 pharmacist interventions were made, averaging 4 interventions per patient. CONCLUSIONS: Pharmacy discharge counseling was associated with reduced 30-day readmission rates in those patients at moderate risk for readmission.

Characterization of ATP-independent ERK inhibitors identified through in silico analysis of the active ERK2 structure.

The extracellular signal-regulated kinases (ERK1 and ERK2) are important mediators of cell proliferation. Constitutive activation of the ERK proteins plays a critical role in the proliferation of many human cancers. Taking advantage of recently identified substrate docking domains on ERK2, we have used computer-aided drug design (CADD) to identify novel low molecular weight compounds that interact with ERK2 in an ATP-independent manner and disrupt substrate-specific interactions. In the current study, a CADD screen of the 3D structure of active phosphorylated ERK2 protein was used to identify inhibitory compounds. We tested 13 compounds identified by the CADD screen in ERK-specific phosphorylation, cell proliferation, and binding assays. Of the 13 compounds tested, 4 compounds strongly inhibited ERK-mediated phosphorylation of ribosomal S6 kinase-1 (Rsk-1) and/or the transcription factor Elk-1 and inhibited the proliferation of HeLa cervical carcinoma cells with IC(50) values in the 2-10 microM range. These studies demonstrate that CADD can be used to identify lead compounds for development of novel non-ATP-dependent inhibitors selective for active ERK and its interactions with substrates involved in cancer cell proliferation.